With funding from the

Pathways of Women’s Empowerment Research Programme The Pathways of Women’s Empowerment Research Consortium Programme Consortium (www.pathwaysofempowerment.org) www.pathwaysofempowerment.org links academics, activists and practitioners working to advance women’s empowerment locally, regionally and through global policy IDS Sexuality and Development Programme Everything you processes. Its network is organized around five research institutes: http://www.ids.ac.uk/go/sexualityanddevelopment • BRAC University (Bangladesh) with partners in the South Asia region The Pleasure Project • Centre for Gender Studies and Advocacy at the University P.O. Box 1502 of Ghana (Ghana) with partners in West Africa wanted to know Oxford OX4 9ED UK • The Interdisciplinary Women’s Studies Nucleus at the Federal +44 (0)7962 545 160 University of Bahia (Brazil) with partners in Latin America [email protected] • Social Research Centre at the American University in Cairo www.thepleasureproject.org (Egypt) with partners in the Middle East about pleasurable • Institute of Development Studies (UK) (coordinating organization) © The Pleasure Project, 2008 • UNIFEM at global, regional and national levels. The Pleasure Project (www.thepleasureproject.org) is an The Pathways of Women’s Empowerment Research safer sex but were international education and advocacy organization working to Programme Consortium is funded by the United Kingdom eroticize safer sex. It builds bridges between the health sector Department for International Development (DFID). The views and the sex world, and helps to develop the evidence base for a expressed here do not necessarily represent those of DFID. sex-positive approach to safer sex. It promotes sexual health and prevention of sexually transmitted infections, including HIV, by afraid to ask. encouraging sex education with an emphasis on ‘good sex’, and Pathways of Women’s Empowerment RPC by focusing on one of the primary reasons people have sex –- the Institute of Development Studies at the University of Sussex pursuit of pleasure. Brighton, BN1 9RE UK +44 (0)1273 678490 Twenty questions on sex, The Pleasure Project provides training, consultancy, research and [email protected] publications for sexual health counsellors, NGOs and others who want to take a more sex-positive approach to their work, and it pleasure and health helps erotic media producers to incorporate sexy safer sex into The IDS Sexuality and Development Programme undertakes porn films and other media. The Pleasure Project was started research and communications on how development can better in 2004 at the International AIDS Conference in Bangkok and support sexual rights. It is funded by the United Kingdom since then has provided condom consultancy for erotic films and Department for International Development (DFID) and the Swedish pleasure proficiency training for sex educators, and has mastered International Development Cooperation Agency (SIDA). The the art of erotic condom demonstration. views expressed here do not necessarily represent those of DFID. Sexuality and Development Programme, Institute of Development Studies at the University of Sussex, Brighton, BN1 9RE, UK, www.ids.ac.uk/go/sexualityanddevelopment Acknowledgements Wendy Knerr and Anne Philpott We would like to thank the Pathways of Women’s Empowerment (www.ids.ac.uk/go/sexualityanddevelopment), for funding and Research Programme Consortium, DFID and SIDA, which supporting this publication. Juliet McEachran for significant research generously funded the research on which this publication is based, inputs. And to: Elizabeth Pisani and Henry Armas for reviewing the and Andrea Cornwall, Tessa Lewin, Jenny Edwards, and Megan original draft and providing insightful comments; Kristina Ferris and Donnelly of the Institute of Development Studies (IDS), University Jerket Edstrom for their editing and advice; and Susie Jolly for her of Sussex, for facilitating this grant and giving valuable feedback. ongoing support for this project and many other aspects of our work.

We would also like to extend a big thank you to Kate Hawkins Design by Marten Sims // [email protected] and the IDS Sexuality and Development Programme

2 3 Contents

1. Why do people have sex? 2. Is sex rational? 3. What is sexual pleasure? 4. What shapes sexual pleasure? Why do people 5. Are societies sex-negative or sex-obsessed? 6. What do women want and feel? 7. What about men? 8. What is safer sex? have sex? 9. How do people make decisions about safer sex? Quick and dirty answer: 10. Are safer sex campaigns too negative? People have sex for many 11. Who says there’s not enough pleasure in sex education? reasons, and sexual pleasure 12. What’s wrong with sex-negative public health campaigns? 13. Do positive attitudes about sex correspond to positive attitudes about safer sex? is primary among them. 14. Can eroticizing safer sex improve people’s attitudes about safer sex? 15. Can eroticizing safer sex lead people to practice safer sex? 16. What are safer sex skills and why are they important? 17. How do you eroticise safer sex? 18. How can we teach people (or how do they learn) about sexy safer-sex? 19. What do we recommend? 1. 20. Where did we get our answers from (i.e. What was our methodology)?

Limitations

(or, “We did our best”) Pleasure is arguably, if not (Browning et al., 2000), for reproduction, as part of a social contract such as marriage, in response to This review came from an original evidence review on sexual health and sex education (and on many definitively, the single most pressure or coercion, recreation or play (Rye, 2007), of women’s empowerment and sexuality. It is based psychology topics) has taken place in high-income powerful motivating factor or to earn a living. on the available and admittedly limited research countries, particularly the United States, there are for sexual behaviour.” that exists on safer sex, sexuality and pleasure (see significant and troubling geographical and contextual However, sexual pleasure remains a highly – World Association for Sexual Health (WAS), 2008 Question 20 for more information on our methods). biases in the understanding of sexuality and pleasure, significant, if not primary, motivating factor for sexual As a result, some topics are not represented as which are inevitably reflected in this publication. behaviour (World Association for Sexual Health equitably or prominently in this publication as we While we acknowledge these limitations, we hope this Sexual activity can be consensual or forced, (WAS), 2008; Rye and Meaney, 2007; Pinkerton et would have liked. For example there has been document can enable practitioners to enhance their pleasurable or not. It can involve one person, al., 2003). Since HIV is spread mainly through sexual severely limited research on the sexuality, pleasure sexuality education and sexual health programmes two people or many people, of any gender, and transmission (e.g., WHO, 2003; Over and Piot, 1993; and safety of lesbians and transgendered people, and activities, while giving researchers, funders and it can serve a wide variety of needs. People have Boyce et al., 2007) , efforts to prevent HIV need to thus these groups (and issues related to diverse programmes evidence and encouragement to consider sex for many reasons: love and affection, bonding, consider the role that sexual pleasure and desire play sexual identities in general) do not feature strongly in increasing their focus on sex and pleasure for people conformity, recognition, power, stress reduction in sexual behaviour (WAS, 2008). this publication. In addition, because most research of all sexual identities and in all settings and contexts.

4 5 Quick and dirty answer: It can be, but that depends on what you mean by ‘rational’. Is sex Decision making is influenced by desire, biology and other needs, and sometimes even unsafe sex can be a very rational? rational choice.

The psychology literature includes various or ‘rational’ frame of mind (Boyce et al., 2007). This is not to say that young people do not exercise studies on how people make decisions about While interventions based on so-called ‘rational’ control over their sexuality, but rather that the process sex and safer sex, and how this might influence decision making have been shown to be effective in of sexual decision making is not as simple as an Can a person be ‘turned risk-taking behaviour. The actual psychological increasing people’s health knowledge and improving assessment of possible consequences. Can a person on’ and still make 2.processes which lead to risk-taking behaviour are their attitudes to safer sex, they do not necessarily be ‘turned on’ and still make rational decisions? In rational decisions? In not well-understood, especially when it comes to sex increase safer-sex practices (Albarracin et al., 2003). interviews in Zimbabwe, Masavaure (2008) found that interviews in Zimbabwe, (Janssen and Bancroft, in press). However, there are the young women were not impulsive, but rational In ‘Putting sexuality (back) into HIV/AIDS’, Boyce Masavaure found that the indications that the great majority of HIV prevention and totally aware of the risks of HIV, which they had et al. (2007) point to inappropriate approaches to interventions, which largely focus on risks rather than been living under the threat of all their lives. These young women were not sexuality and rational models of sexual behaviour benefits of sex and safer sex, are missing the mark women considered their options and yet still chose impulsive, but rational and as key reasons for the failure of HIV prevention (Albarracin, 2003). to have pleasurable sexual experiences, even when efforts. Interventions which seek only to increase totally aware of the risks of there may have been risks involved. Many biomedical interventions aim to improve people’s knowledge about health risks are unlikely HIV, which they had been knowledge and awareness of health risks as a to be effective, they say, because sexual behaviour The notion of ‘rationality’ ignores the many other living under the threat of way to reduce risk behaviours. This is based on is motivated not simply by health, but also by desire motivators for unsafe sex and unhealthy behaviour, all their lives. These women the assumption that individuals weigh the pros and (Boyce et al., 2007). A study of young people in which may, in fact, be very ‘rational’. For example, considered their options cons of a sexual act and consider the potential Vietnam reinforces this, concluding that: if suggesting condom use to a partner could lead to and yet still chose to consequences (often referred to as ‘rational’ decision violence, peer pressure or other negative outcomes, “[s]exuality is perceived in direct opposition to making). Various studies, however, argue that the decision not to demand condom use could, in fact, have pleasurable sexual everyday modes of consciousness and to the this is a ‘rationalist fallacy’ – decisions about risk- be interpreted as a highly ‘rational’ decision. Clearly, experiences.” capacities for rational planning and self-control taking, particularly with regard to sex ‘in the heat more research is needed in this area, and it is crucial which youth normally consider themselves to of the moment’, are rarely made in a conscious to look at other factors that may affect sexual decision possess” (Gammeltoft, 2002, p490).”

7 making, such as gender, culture, pleasure and desire, “[r]omance gives meaning and impetus to sex that which will be addressed in subsequent chapters. should be acknowledged in safe sex education. Quick and dirty answer: It is necessary to consider the possibilities There are as many definitions of Taking a broader approach, Scott-Sheldon et al. What of women’s interest in romance to avoid an sexual pleasure as there are people (2006) looked at impulsive psychological processes unintended effect of safe sex promotion in further in the world – it is personal and involved with decisions to use or not use a condom. individual, and can be culturally denigrating and marginalizing the concerns is sexual They tested this through free-listing research or socially defined. Understanding and experiences of women. The meanings of – recording the simple, quick associations with this diversity is crucial for pleasure- romance are not fixed and immutable, and we condoms that come to people’s minds – with groups pleasure? focused HIV prevention. need to think about how it can be represented to of heterosexual men and women and gay men. They reflect different sets of concerns as well as more found that nearly half of the immediate thoughts diverse fields of desire and pleasure.” about condoms related to sexual or sensual factors, Sexual pleasure, like sex, is difficult to define. It enjoyment or pleasure from the work or transaction, while under a quarter concerned protection, and even So while the form romance currently takes in many can involve orgasm, but does not have to; and it such as sex workers (e.g., Hazra, 2006, discusses this in fewer specifically concerned pregnancy prevention cultures seems to discourage safer sex, this is not is influenced by an unlimited range of factors. In relation to male sex workers in India) and young women or disease. They suggested that these quick necessarily an intricate characteristic of romance, but many cultures, satisfying sexual activity is defined who have relationships with ‘sugar daddies’, such as associations may be better predictors of condom rather one set of meanings that it has acquired. in relation to what gives men pleasure (Marcus, those in the Gambia interviewed by Nyanzi (2004). use than neutral attitudes and intentions. 1993; Gordon and Lewis, 2005), and there has been While the diverse ways that people define sexual disproportionate focus on the idea that ‘sexual pleasure They are careful to point out, however, that a major pleasure is under-researched and under-reported, it Romance gives meaning equals orgasm’. Overall, the public health sector has limitation is the fact that condoms are largely seen as is clear that cultural notions of what constitutes sex and impetus to sex that dealt with the concept of sex – or more specifically decreasing sexual pleasure (Fisher, 1984, in Scott- and what is pleasurable have massive implications for should be acknowledged sexual activity – largely in the context of penis-in-vagina Sheldon et al., 2006). effective HIV prevention, and prevention work must penetration for the purpose of procreation, or penis in in safe sex education. It is open up a dialogue about how the regulation of sexual Warr (2001) notes that, “young women’s commitment anus or mouth, while ignoring the wide range of other necessary to consider the 3.pleasure is understood in different cultures (Gordon to popular forms of romantic love place a high value activities that people find sexual or stimulating. on sexual exclusivity, trust and surrender.” Romantic possibilities of women’s and Lewis, 2005). Some groups in Uganda, such as love may not always be rational and it may reinforce interest in romance to What is clear is that sexual pleasure is not always the Baganda or Busoga, emphasize both male and gender norms which do not act in support of safe sex. avoid an unintended effect directly linked to arousal or orgasm. For instance, female pleasure and practise sexual activities other Complying with a romantic view of relationships – Senegalese women who had undergone clitoridectomy than penetration. In contrast, other groups such as of safe sex promotion reported that they experienced pleasure during sex, the Acholi and Lugbara, focus almost exclusively on where trust and surrender are paramount – may mean in further denigrating that you stop or do not use condoms as a sign of suggesting that pleasure is not just something biological penetration and ‘rough’ sex, which has an increased your commitment, trust and love (Escabi et al., 2004; and marginalizing the (Dellenborg, 2004). Cross-cultural research has found risk of HIV transmission (Marcus, 1993). Some Kamya et al., 2002; Foss et al., 2004; Salazar et al., concerns and experiences that sexual pleasure has been defined by women as cultures have a preference for penis ‘enhancements’, 2002). Warr acknowledges that the romantic narrative of women.” involving factors as diverse as marital harmony (George, penis cutting or insertion of objects into the penis, may at times put women at risk, she argues that: 1998) and men’s contribution to household tasks and which are done with the intention of enhancing – Warr, 2001 expenditure, as well as by the absence of gender-based sexual pleasure (Yuntadilok et al., 2002; Hull and violence (Welbourne, 2006). Sexual pleasure can also Budiharsana, 2001). Beliefs about pleasure and sexual be associated with safety, for example, when the use fluids can also influence safer-sex practices, such as the of condoms creates a more relaxed, less stressful preference for dry vaginas in some cultures (Gordon and sexual experience (Jolly, 2007; Becker, 1997). Lewis, 2005), which can increase risk of infection.

Some researchers are quick to assume that many While it is difficult – and perhaps ill-advised – to try to sexual acts do not involved pleasure at all, particularly formulate a single definition of ‘sexual pleasure’, it is where sex is a weapon of war, and also where sex is important to consider conceptions of sexual pleasure exchanged for money or other commodities (Boyce if we are to have pleasure-focused HIV prevention. et al., 2007). However, the latter can be disputed as Efforts to use pleasure and desire as motivators for pleasure is often (if not always) relevant in the context of safer sexual behaviour require an understanding of 1. HIV is transmitted though: unprotected penetrative (vaginal or anal) and oral sex with an infected person; sex work, since part of a sex worker’s job is to provide sexual pleasure crafted in a way that makes it useful blood transfusion with contaminated blood; by using contaminated syringes, needles or other sharp instruments; from an infected mother to her child during pregnancy, childbirth and breastfeeding (UNAIDS Fast Facts about HIV, sexual pleasure. In addition, some people who receive in research and programmes – in other words, there http://data.unaids.org/pub/BaseDocument/2008/20080501_fastfacts_prevention_en.pdf, accessed 26 May 2008). money or other commodities in exchange for sex report is a need to ‘operationalize’ notions of pleasure.

9 What shapes Quick and dirty answer: Society, culture, peers, gender, class, past experiences and lots of other factors shape sexual a person’s notion of pleasure. People may experience pleasure from things that are socially or culturally acceptable (e.g., sex in marriage), and/or from things that are 4.pleasure? not (i.e., taboos).

While there are different views on what shapes randomized control trials and other research into the and domination. Pleasure can be about power sexuality and notions of sexual pleasure, it links between pleasure and safer sex have taken place (Cornwall, 2006); and Singhal (2003) cites the work is widely accept that society plays some role in a narrow range of countries and cultures, such as the Safer-sex and HIV of anthropologist Richard Parker in Brazil, on erotic (Dowsett, 2003), including a role in controlling USA, and mostly in a narrow range of populations, such prevention work needs experiences which undermine public norms in private and regulating sexuality and pleasure (Gordon as among university students. Yet culture and context to take account of how places. He suggests this notion of the social and and Lewis, 2005). In recent years a number of are crucial for designing effective and appropriate HIV pleasure is constructed, as cultural construction of eroticism could explain the authors have highlighted the crucial importance not prevention interventions (Boyce, 2007). reasons that: only of society, but of culture, context, gender and well as the diversity in how Anthropological research has emphasized the ways “A happily married man, with a steady home life other macro-social elements on sexual decision pleasure is experienced and degree to which a person internalizes cultural and children, visits commercial sex workers. making and aspects of sexuality, particularly in by individuals in different messages about sex and sexuality, and how this has Within four walls, a sex worker may perform a the context of HIV prevention (for example, see profound effects on the way a person experiences contexts.” range of sexual acts that a ‘proper’ wife would Gammeltoft, 2002; Boyce et al., 2007; Dowsett, sexual pleasure (Rye, 2007; Boyce, 2007). In addition, – Gordon and Lewis, 2005 shun” (p23).” 2003; IDS, 2006). some anthropologists and ethnographers have found what is culturally sanctioned – the opposite is often On the other hand, some women report that if they Safer-sex and HIV prevention work thus needs to take that conceptions of both pleasure and health can differ true. Sex and sexuality are strongly influenced get too excited during sex, their husbands ask why account of how pleasure is constructed, as well as the conceptually as well as linguistically (Boyce, 2007). In by social norms, which define various attitudes, they are acting like prostitutes, according to a study diversity in how pleasure is experienced by individuals other words, some languages may not have a word behaviours and activities as either ‘acceptable’ or in Nigeria (Akenova 2008). In other words, different in different contexts (Gordon and Lewis, 2005). for concepts that researchers and others from the ‘taboo’ (Rye, 2007). The source of sexual pleasure sexual behaviours are accepted and expected ‘west’ think is fundamental to human experience. However, sexual pleasure in the context of research and for some people might be condemned as harmful according to gender and type of relationship. This study is neither simple nor straightforward, especially Yet it should not be assumed that people experience or violent by mainstream culture (Hazra, 2006) – for has profound implications for how we conceptualize across cultures (Boyce, 2007). The great majority of sex, sexuality or sexual pleasure based solely on example, in the case of sadomasochism, bondage pleasure in sexual health programmes.

10 11 While negativity about sex is found in many cultures, there is a concurrent obsession with the pleasures of sex.”

Many cultures generally consider sex to be a destructive or dangerous force, and religious institutions often characterize sex as negative. Foucault talked about the punitive social framework in which sex is enacted, both formally and informally (Foucault, 1978). Christian tradition, for example, sees sex as inherently sinful and genitalia as an inferior part of the body (Rubin, 1984). Consensual sexual acts – including homosexual sex and adultery – are grounds for punishment (such as stoning), imprisonment or even death in countries such as Iran, Uganda and Saudi Arabia (see, e.g., Mir Hosseini, 2010; Alsop, 2009).

The negative treatment of sex and sexuality can be seen in hierarchical systems which categorize sex acts based on their assigned social or cultural value, Are societies for example: monogamous married heterosexual sex is highly valued or permissible, solitary sex is more taboo, and the behaviour of sex workers, transvestites and promiscuous single women are at the lower end of the continuum. This categorization sex-negative... has been sanctioned in medicine and psychiatry, where sexual differences, such as homosexuality, have been classified as ‘abnormal’ or pathological (Rubin, or sex-obsessed? 1984) until recently (and still are in some countries). While this negativity about sex is found in many Quick and dirty answer: cultures, there is a concurrent obsession with the Negativity about sex is found in most cultures and pleasures of sex. This can be seen, for example, in institutions (e.g., religions), but this often exists alongside pornography, women’s magazines, popular culture, an obsession with the pleasures and importance of sex marriage songs, and marriage preparation rituals. While this obsession may be with sexual pleasure (e.g., in the media, among peers), though often among that occurs in the context of narrow gender roles a select group (e.g., passive women, and people who (e.g., submissive woman, dominant man, or women are married, young, and heterosexual). as objects), it still suggests that the cultural and religious negativity related to sex exists alongside a glorification of sex and sexual pleasure. 5.12 13 Conceptualizing sex, sexual pleasure and safer sex for the purposes of public health interventions is an ongoing challenge that has to account for Where a woman’s or girl’s a wide range of factors, not least of which are virginity is valued, she gender and power relations. Ignoring gender issues may practice non-vaginal can lead to wasting resources on ineffective prevention sex, such as anal sex, programmes (Population Council, 2001), and could which, without condoms or also have detrimental effects on individuals. lubricant, can place her at The common gender norm of women as passive and increased risk for HIV.” ignorant makes it difficult for women to be informed – Rao Gupta, 2000 about sex, sexuality and safer sex (Rao Gupta, 2000). In many cultures and contexts, women are at Bangladesh found that more than half (53%) reported risk of violence or other negative consequences if having ‘love’ marriages (i.e., not arranged marriages). they are seen to ‘enjoy sex too much’, because this While a majority described husbands pressuring them brings into question their virginity or fidelity (ICW, to have sex, a minority did report mutually pleasurable 2004). Women who have sex with women are less sexual relations with husbands. They also recognized What do visible in discussions of HIV risk and sexual health, that being young and attractive can translate into partly because women to women sex carries almost economic power (albeit temporarily). One declared: no risk of HIV but also they hidden due to stigma, and the myths that women cannot find sexual satisfaction “My husband is older than me. His first wife has big with other women. The focus on ignorance and virginity saggy breasts and because she is older he does not as ‘feminine’ increases risks of HIV infection, as it like her any more, and that is why he has married women keeps women uninformed about sexual health, and again. It does not matter that I am his second wife; this is often compounded by erroneous beliefs and I have much more pull over him and he has more myths about sex, such as that men can be cured of HIV affection for me ... he can never, ever say no to infection by having sex with a virgin (Rao Gupta, 2000). me! He gives me two-thirds of his income, but he gives her so much less!’ (Faiz Rashid, 2006, p74). There is evidence that where a woman’s or girl’s want virginity is valued, she may practice non-vaginal In a different region, Isatou Touray provides a 6. sex, such as anal sex, which, without condoms or perspective of older first wives in the Gambia, lubricant, can place her at increased risk for HIV reporting that they face ‘forced retirement from sex’ (Rao Gupta, 2000). And where motherhood is after menopause if their husbands marry younger highly valued, it may be difficult or impossible for women. They are left unsatisfied, but unable to leave a woman to negotiate safer sex, such as barrier the marriage or seek sex elsewhere due to social and and feel? methods or non-penetrative sex. This is further economic constraints (Touray, 2006). complicated by the common belief that women only Quick and dirty answer: Masvaure (2008) interviewed female students at a have sex for procreation while men ‘need’ sexual There has been very little research into what women Zimbabwean university, and concluded they shape release (Goldstein, 1993). Finally, women may stay their sexual lives round their own sexual pleasure. find pleasurable. When women do report on their own in relationships which do not meet their desires She challenges researchers and others to pay pleasure, it is sometimes ignored because it doesn’t fit for many reasons, such as economic dependency, attention to these ‘sex as pleasure’ conceptions of stigma around divorce, or lack of security for single the stereotype of women as passive victims of sex. young African women, and suggests that these types women. However, it should be noted that, in many of stories may seem rare because they do not fit with parts of the global South, there are examples of the women-as-victims views held by most people. She women finding pleasure in a range of relationships describes the female students in her study as “active (Tamale, 2005; Ilkkaracan and Seral, 2000). lust seekers” and points out that their experiences Ethnographic field work carried out among 153 show how prevention programmes are out of touch married girls aged 15–19 in a Dhaka slum in with the real lives of young African women.

14 15 We must challenge gender norms, and start an informed discussion about cultural beliefs surrounding male sexuality, including performance and pleasure, or else condom use will remain difficult and a potential source of anger and frustration for men.” – Jill Lewis, 2006 What about men? Quick and dirty answer: The assumption that women are victims and men is generally assumed to be a threat to women, and expectation that they had to ‘keep it up’ at all costs. are predators means that men’s needs and interests women are expected to resist it. Ignoring men’s real needs and Research in Kalemie, Congo, found that men in some and the pressures they face in relation to sex and desires is detrimental to (men’s Some researchers have concluded that using communities believed they had to regularly inject sexuality are often dismissed or ignored. Men are and women’s) health and can condoms, which are perceived to reduce men’s sexual sperm into women’s bodies to avoid going insane; expected to ‘know’ how to have sex (UNAIDS, 2000; render safer-sex messages pleasure, and practising non-penetrative sex as safer and work in Monrovia found that some men believed Rao Gupta, 2000) and, in most cases, how to give ineffective. Beliefs about sex can be threats to masculine identity, and therefore women could not experience sexual pleasure without sexual pleasure to women. Yet the pressure to ‘just masculinity (e.g., what ‘real difficult to promote (Flood, 2003). In the same way the men ejaculating into them (Lewis, 2006). As a know’ prevents young men from seeking out information that women are assumed to be victims or not actively long-term strategy, some researchers recommend men’ should do) can hinder about sex and sexual health and from admitting they do engaged in creating their sexual cultures and pursuing challenging gender norms and starting an informed safer sex practices, or can be not know. This often leaves them to experiment with sex sex and sexual pleasure, HIV research and safer-sex discussion about cultural beliefs surrounding male used to promote safer sex. at a young age, in potentially unsafe ways, as proof interventions often assume what men do or do not find sexuality, including performance and pleasure, or of their masculinity (UNAIDS, 1999. 2000). pleasurable, and this assumption can be used to argue else condom use will remain difficult and a potential According to Rao Gupta (2000), beliefs and myths against condom use (Lewis, 2006). For example, source of anger and frustration for men. about masculinity challenge many aspects of safer-sex recent research in Brazil found that men’s and boys’ However, there may also be scope for working programming; for example, the belief that men need a complaints about a reduction in sexual pleasure within existing gender norms as a short-term route wide variety of sexual partners and are dominant over when using condoms were largely related to a deeper to condom promotion, without condoning harmful women by nature, or the stigma associated with same- anxiety with sexual performance – namely the fear practices or gender stereotypes. For more information sex sexual relations. Invulnerability is also a common of losing their erection when putting the condom on about this, see Question 17: which techniques masculine expectation, which stands in opposition (Population Council, 2001). So it was not condoms per work to eroticise safer sex? to the need to protect oneself. Overall, men’s desire se that were the problem – it was the perceived or real 7.16 17 Image by Sikander [email protected] What is

The definition of safer safer sex? sex can be influenced Quick and dirty answer: by cultures and contexts Doing what feels good, and doing it safely. However, the but also by political and ‘official’ definition varies according to culture, context, the moral or religious forces, media, and moral and religious forces, as well as science. often to the detriment of people’s health.” – Cindy Patton, 1989

‘Safer sex’ is not a simple concept to define. exaggerated danger and expected too much, thereby through penetrative sex (Maxwell and Boyle, 1995; more common in some gay male communities, for According to Patton (1989) putting people at increased risk of HIV (Moore, 1997). Bezemer, 1992). Thus, despite the fact that many non- reasons such as ‘condom fatigue’, the feeling of Moore describes the approach in countries such penetrative sexual activities can involve less risk of HIV relative safety when both partners are HIV-positive, “...the safer sex message is about sexual practice as the USA and UK as “differentiated risk”, which than many penetrative activities, the notion that ‘sex and the belief or feeling that it is more intimate or a and is quite simple. It was eloquently stated by a involves a spectrum of risk. This ranges from very equals penetration’ makes promoting non-penetrative greater thrill than sex with condoms (Pozlife, 2006) gay man with AIDS who is a safer sex educator: low-risk activities, such as sensual massage, hugging, sex difficult (Maxwell and Boyle, 1995). It should be ‘Whatever you want to do, you can probably do it The definition of safer sex can be influenced by cuddling and snuggling; to possibly safe practices noted, though, that penetration-as-pleasure is not safely.’ …But the public AIDS discourse equates cultures and contexts but also by political and such as French kissing and anal intercourse with latex exclusively the domain of men: many women also view condoms and/or celibacy with safer sex, ignoring moral or religious forces, often to the detriment of condoms; to possibly unsafe practices such as oral sex penetration as an important expression of intimacy, as the wider range of safe sex practices” (p241). people’s health (Patton, 1989). For example, the US 8.without a latex barrier (especially during menstruation). a means to become pregnant, which is an important government’s ABC policy emphasized abstinence What is clear is that there is no standard meaning of Finally the spectrum includes unsafe practices such status marker in many societies (Maxwell and Boyle, over other forms of sexual practice and suggested it safer sex, and this is problematic. as anal intercourse without a condom and sharing 1995), and as a pleasurable activity in its own right. is the only definite way to avoid HIV. This, explains needles or blood while piercing or injecting drugs. The “The inability to decide specifically what is safe In the USA, the focus of HIV prevention and sex Pisani (2008), is an example of “how religious dogma categories of ‘possibly safe’ and ‘possibly unsafe’ are and unsafe has prevented many groups from education on abstinence and the dangers of sex crushes our efforts to translate good data into good constantly being reformulated (Moore, 1997). recommending what is safe in broad terms. … was found to lead young people to practise oral sex, HIV prevention.” According to Patton (1989): This mixed message leaves people confused The focus on condoms as the optimum safer-sex which they did not consider ‘real sex’, but which has “[Safer sex] is not a moral category to sweep up about what is unsafe and gives an underlying practice to prevent HIV has been widely criticized, lower risk for STIs and unwanted pregnancy (Hopkins sexual practices with which we feel uncomfortable impression that everything is equally unsafe” because it implies that penis-in-vagina sex is the Tanne, 2005). Abramson and Pinkerton (2002) suggest for other reasons. Gay sex can be safer. S/M can (Patton, 1989, pp239–40). only ‘real’ sex (Bezemer, 1992). It also tends to focus that gay men more easily embraced safer sex because be safer. Anonymous sex can be safer. Bisexual attention on male pleasure, while non-penetrative they knew that sex is not just about penetration, thus The meaning of safer sex can vary by country; for sex can be safer. Monogamy in itself is not safer, (and often safer) forms of sex are considered they practise a wider range of sexual activities and example, research in the 1980s showed that in the and, though a valid option for any number of ‘foreplay’ – only a preliminary act before the ‘real’ sex behaviours (some of which could have been lower-risk UK, HIV prevention focused on risk reduction, while reasons, carries its own dangers – spouse abuse happens (Maxwell and Boyle, 1995). This is despite than penetration). However, over the past ten years, in the USA prevention was aimed at the seemingly and all the traditional hazards of ‘marriage’.” (p244). the fact that most women report not achieving orgasm ‘bare-backing’ or condom-less anal sex has become unattainable goal of risk elimination. The latter

18 19 reinforcement value – in other words, it promised How do more physical pleasure and intimacy with a partner Are safer sex – while there was a lack of reinforcement value people make (benefits) associated with safer sex. The authors decisions concluded that prevention approaches need to campaigns too include the reinforcement value – in other words, the about safer sex? benefits – of safer sex (Kelly and Kalichman, 1998). There are also wider social and cultural factors that sex negative? Quick and dirty answer: Research does not support the idea influence these decisions. For example the belief Quick and dirty answer: that condoms are only used with ‘unsafe’ partners, In short, yes; but there have been good examples of sex-positive that people (especially young people) campaigning (e.g., gay men’s prevention efforts in the early years of are unaware of the risks of unsafe sex. prostitutes or casual sexual partners, but using one AIDS) and efforts to shift the focus to pleasure (e.g., The Pleasure Project). People are known to choose unsafe with a regular partner indicates a lack of trust. sex because they perceive it to offer more benefits (e.g., pleasure, social “Women would regard it as an offense if their Pleasure and eroticization have been elements of ordinarily taboo issues in many settings (e.g. Laurance, acceptance, pregnancy) than safer sex. male mates intended to use condoms with them, 10.grassroots-level HIV interventions for decades. At 2008; Johnson, 2005). However, public health discourse since they claimed to be ‘clean’ women. For gay/ the beginning of the HIV epidemic, organizations and campaigns still tend to ignore sexual pleasure bisexually identified men, who report a more focused on prevention among men who have sex and desire, or to focus largely on negative aspects frequent use of condoms, lack of use is justified as with men integrated erotic safer sex concepts into of sex and sexuality (Pigg, 1999; Gosine, 2005). a result of a more intimate relationship, or as related many of their prevention efforts (Patton, 1989). Non- There is a common belief that young people are There is a growing body of literature that emphasizes to power imbalances” (Salazar et al., 2002, p1). governmental organizations, such as the International the need for the public health discourse to incorporate not aware of the risks of unsafe sex, and therefore Planned Parenthood Federation (IPPF) (Cardinal sexuality, rather than just sexual activity and reproduction, we need to put a lot of effort into increasing their Sex work adds new layers of complexity to our et. al., 2009), the HIV/AIDS Alliance (http://blog. as a key element of programmes and policy. This is knowledge about the risks. However, research does understanding of decision making with regard to aidsalliance.org/2011/05/ microbicides-and-safer- particularly the case with respect to how sexuality not necessarily support this. For example, a US study safer sex. Even when sex workers and others who and-pleasurable-sex/) and The Pleasure Project intersects with human rights. According to the World found that the majority of young people could identify trade sex are aware of the risks of unsafe sex, they (www.thepleasureproject.org) have made strides in Association for Sexual Health: many of the health risks involved with having sex, may not always be able to practise safer sex. For promoting sex-positive approaches in recent years. example, in many places the simple act of carrying using a condom and not using a condom; but this “Sexuality is a central aspect of being human condoms can be construed as evidence that a person However, in large-scale or state-sponsored programmes, did not translate into positive attitudes about safer throughout life and encompasses sex, gender is a sex worker, which invites police harassment in the context of international development, and sex (Widdice et al., 2006). Participants identified identities and roles, sexual orientation, or arrest. And when a client is unwilling to use a with risk groups other than men who have sex with various risks of using condoms – primarily the risk of eroticism, pleasure, intimacy and reproduction. condom, it is not a matter of making a ‘safer sex’ men, safer sex promotion campaigns and research decreased pleasure. When asked about the benefits Sexuality is experienced and expressed in decision for people who rely on sex work for their continue to be overwhelmingly negative, focusing of not using a condom, the most common response thoughts, fantasies, desires, beliefs, attitudes, livelihoods (Jayasree, 2004). on fear, risk, disease and the negative outcomes of was increased pleasure. Widdice and the other study values, behaviours, practices, roles and authors concluded that researchers and others who sex (Singhal, 2003; Philpott et al., 2006; Ingham, Where sex takes place can also be a factor. When it relationships. While sexuality can include all of want to increase safer sex practices should widen 2005). In fact, the pursuit of sexual pleasure, takes place outside or in empty buildings (especially these dimensions, not all of them are always the focus to include psychosocial benefits, such when mentioned, has even been characterized as where certain types of sex are illegal or stigmatized, experienced or expressed. Sexuality is influenced 9.as peace of mind, in addition to discussing risks destructive (WAS, 2008) or as a major contributor such as gay sex), condoms or lubricants may not be by the interaction of biological, psychological, (2006). Another study found that adolescents were to the spread of HIV, and therefore something to be available or easily used. And where sex workers or social, economic, political, cultural, ethical, legal, more motivated by their beliefs about the perceived controlled or suppressed (e.g. BBC News, 2004; Freitas others, such as men who have sex with men, fear historical and religious and spiritual factors” (2008). benefits of risky behaviours than the costs or dangers et al., 2002). In some cases, the AIDS pandemic has discovery by the police, the need to have sex quickly (Parsons et al., 2000). created an opportunity for more open discussion of (For an overview of sexuality in public health, often precludes the use of condoms (Jayasree, sex, sexuality, sexual behaviour, safer sex and other development and human rights, see IDS, 2006). A study among gay and bisexual men indicated that 2004). The lack of safe spaces for men to have attitudes and intentions related to high-risk sexual sex with men can lead to the practice of quick and behaviour are trumped by the perceived pleasure unprotected sex, yet it must also be recognized that Sexuality is a central aspect of being human throughout life or reward of these activities, otherwise known as sex in public places can be highly erotic and therefore the ‘reinforcement value’. The men practised unsafe not always seen as undesirable, even if it does make and encompasses sex, gender identities and roles, sexual sex because it was perceived to have a higher safer sex more difficult to practise (Jolly, 2007). orientation, eroticism, pleasure, intimacy and reproduction.” – World Association for Sexual Health, 2008

20 21 Who says The public health research community has largely failed to explore the factors that there’s not contribute to optimal sexual functioning for women or the ways in which sexual pleasure-seeking … influence women’s risk enough for unintended pregnancy and disease.” – Higgins and Hirsch, 2007

pleasure in In the area of reproductive health, there have been the other hand, anecdotal evidence that some young calls for a broader definition of sexuality to be men find that condoms enable them to maintain an 11. incorporated into reproductive health, where women erection longer have been largely ignored. (Some sex education are included as sexual beings who can consider commercial condom companies have seized on this in pleasure in their reproductive choices (Dixon-Mueller, recent years by introducing condoms treated with an 1993). When two researchers (Higgins and Hirsch, anaesthetic gel preparation; for example, see 2007) revisited this assertion 14 years after it was http://www.freepatentsonline.com/7086403.html.) originally made, they found that the threats and and safer sex A 1996 article in the British Medical Journal describes limitations to women’s sexual behaviour had been how a public health authority in the UK objected to well documented. However, they also found that: a mainstream (private sector) campaign advertising promotion? “the public health research community has largely travel holidays to people aged 18–30. The health failed to explore the factors that contribute to authority claimed that the campaign promoted the Quick and dirty answer: optimal sexual functioning for women or the ways belief that sex is risk free. In response, the agency Research on sex and sexuality has highlighted the lack of in which sexual pleasure-seeking … influence launched its own campaign using what it describes pleasure for decades, and more recently they have been women’s risk for unintended pregnancy and as “banality rather than carnality” to get across disease” (Higgins and Hirsch 2007a, p133). the message that sex is not risk free (Mendelsohn joined by organizations such as the World Association for and Chambers, 1996). This example highlights the Moreover, there is very little information about how Sexual Health. Abstinence-only education, in particular, interesting contrast between the private sector’s use of contraception affects sexual enjoyment and functioning, has been widely discredited. ‘sex’ to sell products and services, and the public health especially for women (Higgins and Hirsch, 2007b), sector’s primary focus on risk to promote safer sex. even though research indicates that the acceptance of contraception is influenced by how sex feels when using In one instance, an HIV risk prevention programme In 1988, psychologist Michelle Fine criticized transgender youth, are still being ill-served or even a particular method (Higgins and Hirsch, 2007a). among gay men in the 1980s had positive results the anti-sex approach taken within sexuality inhibited by sexuality education legislation and when including a sex-positive, erotic component as education in the United States, stating that this programming (Fine and McClelland, 2006). In terms of male methods, the emphasis has been a sex education tool (Quadland, in Kolata, 1987). approach let down the most vulnerable people on negative aspects of condom use (Moore and More recently, rigorous reviews of programmes However, according to some observers, “intolerance and potentially inhibited the sexual development Helzner, 1997). For example, there have been many promoting abstinence-only education have been of homosexually explicit materials” in the USA in of young people in general. In 2006, Fine revisited studies on what men do not like about condoms, and discredited (e.g., Underhill, et. a., 2007) and even the late 1980s meant that the highly effective video this subject and found that not much had changed informational pieces about condoms have perpetuated linked to harmful outcomes (such as unsafe sex) could not be made available to other researchers or for the better: young women in particular, as well the belief that condoms reduce male pleasure. On (www.guttmacher.org/pubs/gpr/12/1/gpr120106.html). programmers (Marlatt, 1998). as ethnic minorities and gay, lesbian, bisexual and

22 23 What are the effects of sex-negative public health campaigns? Quick and dirty answer: There’s no evidence that sex-negative approaches work better than sex-positive approaches, and in fact negative messages about sex and sexuality can sometimes undermine, rather than promote, safer sex.

While safer-sex practices have increased in some Condom use is not the only practice that has been While the omission of pleasure has such a potentially The author of a 2008 study of young women in contexts and populations (though the long-term or undermined by sex-negative messages. A study limiting effect on sexual health, its inclusion opens Zimbabwe suggests that “young women are not only widespread impact of this is debatable) (Rosser et. from India showed that social condemnation of up salient opportunities, not least the improved at risk of HIV infection in contexts of danger (e.g., such al., 2002), there have been disappointing results masturbation – fuelled by the belief that men are effectiveness of sexual health campaigns. On a as when they are coerced into having sex), but also in even after years of campaigning and education. This weakened when they ‘waste’ semen by ejaculating policy level, the acceptance and therefore inclusion of contexts of pleasure,” thus, public health practitioners is particularly true with regard to the use of male outside a woman’s body – prompted some young men pleasure within sexual health could facilitate “a broader should be programming for pleasure (Masvawure, condoms (Population Council, 2005; Parsons et al., to satisfy their sexual desires by visiting sex workers discussion of sexuality rights, and a recognition of the 2008, p32). Others are calling for a greater recognition 2000; Pisani 2008) and especially among steady and or having male-to-male penetrative sex instead. This agency and abilities of people from the Third World to of the role of sex and sexuality in HIV, arguing that the married couples (Foss, 2004). put them at much higher risk for infections (Deepak make choices about their own lives” (Gosine, 2005, limited conceptualization of sexuality is a major barrier Charitable Trust, 2002, in Ingham, 2005). p.13). This can create a more representative view of to prevention (Boyce et al., 2007; Jolly, 2007). People give many reasons for not using condoms, the many factors that influence sexual choices, and such as: inability to get condoms; misconceptions The emphasis on risk and the omission of pleasure In acceptability trials of the female condom (Philpott, therefore more realistic programmes which reflect about their effectiveness; inability to negotiate condom from public health has broad impacts beyond the 2003; Hapugalle, 2002; HLFPPT, 2004; Telles Dias people’s real sexual lives and relationships (ibid.). use; reduced spontaneity; and the association of individual level. It stereotypes men as predators and et al., 2006) and vaginal microbicides (Whitehead, condoms with illness, casual sex and stigmatized women as victims, and fails to recognize the existence There is anecdotal evidence from a range of countries, 2008; Montgomery, 2008; Sserwadda Luwugge, behaviours (Steiner et al., 2006; Conley and Collins, of transgender people and diverse sexualities cultures and contexts that safer sex, including condom use, 2008) both male and female participants have 2005). In addition, studies repeatedly show that an (Jolly, 2007).12. It also limits, or indeed silences, the can be eroticized and made pleasurable (Knerr and Philpott, reported increased sexual pleasure, or no loss of actual or perceived reduction in pleasure is a major examination of alternative means of giving and 2008; Abramson and Pinkerton, 2002). Indeed, researchers sexual pleasure, when using these technologies, and reason people do not use male condoms (e.g. Niang, receiving pleasure outside of heterosexual penetrative and sexual health practitioners have been calling for a more this has led to their increased acceptance and use. 2002; Scott-Sheldon, 2006; Pinkerton et al., 2003). sex, such as mutual masturbation (Ingham, 2005). The pleasure-focused approach to safer sex and HIV prevention Finally, health organizations such as the World Health In fact, condom campaigns emphasizing disease and lack of sex-positive messages in relation to women in part so that audiences will be more receptive to safer sex Organization (World Health Organization, 2004) and risk have, in some cases, led to the condom becoming and women’s pleasure can lead to the perception that messages and recognize them as relevant to their own sex the World Association for Sexual Health (WAS, 2008) a symbol of death and disease (Abramson and women are not sexual beings, which can influence lives (see Banerjee et al., 2002; Calsyn et al., 2002; Chann now recognize sexual pleasure as a key component Pinkerton, 2002) instead of health. their abilities to decline sex that they don’t want or et al., 2004; Ntahompagaze, 2002; Widdice et al., 2006; of sexual health. don’t find pleasurable (Holland et al., 1992). Population Council, 2005; Abramson and Pinkerton, 2002).

24 25 People with a positive view of their own sexuality are more likely to protect themselves than those less comfortable with their sexuality.” – Higgins and Hirsch, 2007

A 1988 review of research from Canada, Hong acceptance of their own sexuality, and greater Do positive Kong, India, Israel, and the USA found that people consistent condom use at 12 months than the control with positive (‘erotophilic’) attitudes to sex and group. And a 2006 study found a positive association attitudes to sex sexually explicit materials were more likely to use between a woman’s belief that she is entitled to sexual contraception consistently than people who were pleasure, and her confidence in both discussing and 13.characterized as sex-negative (‘erotophobic’) (Fisher knowing how to use condoms (Horne and Zimmer- correspond to et al., 1988). In other words, people with a positive Gembeck, 2006). view of sex and sexuality are more likely to protect positive attitudes A detailed study with teenage girls in the USA found themselves than those who are less comfortable. that those with a more positive view of sexuality were to safer sex? A study in the 1970s and 1980s found that college- more assertive, and knowing what it felt like to want aged American women with more positive attitudes sex meant that some girls could more easily say no to towards sexuality were more consistent users of unwanted sex (Tolman, 2005). contraception, while those reporting feelings of guilt Despite this evidence that attitudes about sex and related to sex and sexuality were less likely to use Quick and dirty answer: sexuality influence safer-sex practices, few evaluations contraception effectively or at all (Gerrard, 1982). of sex education and HIV prevention interventions Yes – the more positive people are A similar result with regard to condom usage was consider the qualitative aspects of people’s sexual about sex and sexuality (and their found among men who have sex with men. Rosser experiences, such as how willingly people engage in right or ability to experience sexual et al. (2000) found a reduction in internalized ‘homo- sex and whether they experience pleasure (Robinson pleasure), the more confident they negativity’ (or homophobia) in the group receiving et al., 2002; Cherry et al., 2005; Haberland, 2007). seem to be about practicing safer sex. a sex-positive intervention; this group had greater

26 27 Adolescents do not have a clear script for sexual Can eroticizing safer behaviour that includes the discussion or placement of a contraceptive ... Failure to integrate information sex improve people’s with sensation occurs because contraceptive information is presented out of the context (or attitudes towards discussion) of sexual activity.” safer sex? – K. B. Kyes, 1990 Quick and dirty answer: Yes – things like erotic safer-sex films and stories have been associated with better attitudes about safer sex, including condom use.

In 1990, researchers found that showing a three- the rate of voucher redemption was used to measure no condoms or instruction. Based on pre- and post- A 2008 study compared Dutch and American minute film featuring a sexually explicit demonstration behaviour change. However, it is plausible that some tests, only the couples who received erotic instruction teenagers, and found that American girls felt a lack of of condom use and advice for incorporating condoms participants could have felt embarrassed to redeem showed significantly enhanced attitudes to condoms control over their sexual experiences, whereas Dutch into foreplay was associated with substantial increases their vouchers on campus and could have purchased after two weeks (Tanner and Pollack, 1988). teenagers usually described their sexual experiences in positive14. attitudes to condoms and the perception condoms elsewhere. Alternatively, the short duration as being wanted, mutually decided and enjoyable. A study comparing frequent condom users to those who of them as pleasurable among young heterosexual of the film (three minutes) may not have been long Dutch teenagers have higher rates of contraceptive use condoms infrequently found two key differences: men and women in the USA (Kyes, 1990). This effect enough to produce an immediate change in behaviour; use and lower rates of unwanted pregnancy, abortion condom users were more likely to believe in their was significant relative to the control group and the there may have been a need to include additional and STIs than their American peers (Schalet, 2008). ability to continue using condoms even in the face of placebo group (those who received no instructions), sexual health information along with the film; or the This is significant because the Dutch teens were barriers (a quality known as ‘action maintenance’), and there was no significant difference in response study may have ended before measurable behaviour likely to have received comprehensive sexuality and they believed that condoms would interfere by gender. This study was testing the use of ‘sexual change took place (Kyes, 1990). education, with a focus on relationship skills that less with their pleasure than did their non-using scripts’, which are said to govern people’s behaviour, foster mutually consensual, pleasurable and In another study, reading erotic stories that feature counterparts (Conley and Collins, 2005). This study and it concluded that sexually-explicit instruction may responsible sex. Their American peers are unlikely to condoms had a positive impact on men’s – but not shows that the correlation can work the other way – be effective because otherwise “adolescents do not have received comprehensive sexuality education, women’s – attitudes towards condoms (Kyes, 1990). not only do people with positive attitudes use condoms have a clear script for sexual behaviour that includes and more likely to have been exposed to sex The authors concluded that erotic representations more frequently, but also, frequent condom users tend the discussion or placement of a contraceptive.” (Kyes, education focused on risks and dangers. can have positive effects on the attitudes of both men to have more positive beliefs about safe sex. 1990, p297). “[F]ailure to integrate information with and women, but the effect may vary according to the Another study found that sexuality education sensation occurs because contraceptive information is Finally, Cohen et al. (1991) cite various studies type of representation. programmes for young people which focus on risks presented out of the context (or discussion) of sexual showing that the ability to eroticize condoms is an and negative outcomes of sexual activity, and which activity,” (ibid, p298). A study among heterosexual couples in the USA important predictor of sexual attitudes and, in some deny pleasure or desire, are prone to “putting off found that presenting erotic instruction with condoms cases, behaviour. (Other predictors include the The study did not, however, show measurable adolescents rather than capturing their attention” significantly enhanced attitudes to condoms availability of condoms, experience and knowledge of behavioural change. This could be explained by (Nyanzi, 2004, in WAS, 2008, p13). compared to control groups. Heterosexual couples condom use, acceptance of condoms by one’s sexual methodological factors, such as how behaviour change were given either: condoms with instructions on how partner, and whether the sexual partner is casual or was measured: study participants were given vouchers to incorporate them into foreplay; condoms only; or regular, or an injecting drug user.) to redeem for condoms at locations on campus, and

28 29 Image by Sikander [email protected] The study concluded that eroticizing safer sex leads to more risk- preventive attitudes, which in turn facilitates less risky sexual behaviour and an increase in condom use.” Can eroticizing safer sex lead people to practice 15. safer sex? Quick and dirty answer: Yes – erotic safer-sex videos, posters, stories, and instruction have all been found to have a positive effect on safer-sex behaviours (but a lot more research is needed!).

A 2006 meta-analysis by Scott-Sheldon and Johnson component (from 7.5% to 100%). All of them were is the most rigorous piece of evidence to date either randomized control trials (the ‘gold standard’ for showing the positive effects of eroticizing safer sex on research) or had a quasi-experimental design with an behaviour. The authors reviewed 21 studies of safer- adequate control group. They showed that participants sex promotion or HIV prevention interventions, all of reduced their risky behaviours compared to control which included an erotic component, specifically: participants and at post-test in six key areas:

• a visual erotic component, such as a video, • HIV-related knowledge; erotic poster or brochure (61%); • attitudes towards condoms; • an activity, such as creating erotic ways to use • reported condom use; condoms or have safer sex, or writing a sexual • communication with sexual partners; fantasy (43%); and • overall behavioural risk; and • reading erotic short stories (20%). • reported decrease in the number of sexual partners.

One-fifth of the interventions used more than one The study concluded that eroticizing safer sex leads method of eroticizing safer sex, and just under one- to more risk-preventive attitudes, which in turn third provided condoms to participants. The studies facilitates less risky sexual behaviour and an increase placed varying degrees of emphasis on the erotic in condom use.

30 31 The 21 studies were primarily done in North America, the study, which appeared in the New York Times, While there has been relatively little research into with one in New Zealand and one in Brazil, at the study authors reported that “the [written] safe sex safer-sex or HIV prevention interventions which universities and schools, and participants were Sexual appeals are more guidelines were ineffective: some men who received incorporate an erotic component, those that have mostly Caucasian men in their early twenties. None attention-grabbing and them gave up sex completely for a time, but did not been done show that this approach improves of the studies took place in sub-Saharan Africa or in more likely to pique change their sexual behavior when they resumed attitudes and intentions related to safer sex and, most countries with high HIV prevalence. Twenty per cent interest in a topic than having relations” (Quadland, in Kolata, 1987, p2). importantly, increases safer sexual practices and/ (20%) of the studies sampled men who have sex with or reduces risky sexual behaviour compared to non- non-sexual appeals, and Finally, a brief (20-minute) intervention focused men, and the researchers found that interventions erotic approaches. This is in stark contrast with non- on showing people how to use condoms and that included an eroticization component improved people are more likely erotic approaches, which impart basic information incorporating positive and erotic messages about male condom use for anal sex. Another important to remember information about HIV, emphasize risks related to HIV, or play condoms reduced the recurrence of STIs among men finding from this research is that eroticizing safer communicated through on pressures and fears related to HIV, and which did (Cohen et al., 1991). The approach did not lead to a sex did not appear to influence the frequency of not increase condom use and in some cases had a such appeals.” reduction in STIs among women, however, and the sex, which confirms other research showing that the negative correlation with condom use (Albarracin et – Richert, 2003 authors urged caution with brief interventions among availability of condoms does not increase sexual al., 2003). The interventions did lead to an increase women, as they may not be sufficient for teaching activity (Scott-Sheldon and Johnson, 2006). in people’s knowledge about HIV and condom use, women with communication skills needed to facilitate and made modest changes in people’s attitudes and Scott-Sheldon and Johnson note that the limited • informational sessions describing AIDS and the negotiation of safer sex. (For more insight on this intentions related to condom use, but this did not evidence for erotic safer-sex interventions makes transmission of HIV; issue, see Kelly, St. Lawrence and Brasfield, 1989, in translate into behaviour change. it difficult to determine whether eroticization or • a ‘visual menu’ of sexually explicit videos and Kelly and Kalichman, 1995.) eroticization in addition to another intervention slides, which presented safer sexual behaviour To date, few studies have analysed the causal link (such as communication skills) is the best recipe for in an affirmative, erotically appealing manner; between erotic safer-sex interventions and safer-sex reducing sexual risk. Nonetheless, they feel their • a didactic presentation (without the audiovisual behaviour change, and most studies have been with study is robust enough to provide reliable evidence materials) presented in an affirmative, erotically While there has been populations in higher-income countries and among that including an eroticization component is an appealing manner; and relatively little research student populations. We now need randomized improvement over other interventions. In addition, • distribution of printed safer-sex guidelines. control trials in low-income settings and settings they cite evidence that including pleasurable or into safer-sex or HIV where there is a high level of risk-taking behaviour. In According to one of the lead researchers: sexual imagery in an intervention could motivate prevention interventions addition, there needs to be a greater analysis of how participation in the intervention (Scott-Sheldon and “The film consisted of three vignettes and showed, which incorporate an men and women differ in terms of erotic interventions. Johnson, 2005). This may be supported by studies for example, two men going on a date and talking erotic component, those done by marketing researchers showing that sexual about safer sex, and then showed one man that have been done appeals are more attention-grabbing and more likely putting on a condom for oral sex. It also showed a …just telling people to to pique interest in a topic than non-sexual appeals, man with AIDS and his lover talking and touching show that this approach and people are more likely to remember information each other and engaging in mutual masturbation improves attitudes and use condoms is like telling communicated through such appeals (Richert, 2003). but avoiding oral or anal intercourse,” (Quadland, intentions related to safer someone to use a saddle in Kolata, 1987, p1). The Gay Men’s Health Crisis study (1987) also sex and, most importantly, to ride a horse – there’s showed positive effects of eroticization on behaviour. Compared to control groups, the group that viewed increases safer sexual a lot more to both safe It found that an intervention which included the the erotic videos and slides was less likely to practices and/or reduces sex and horse riding!” – visual presentation of sexually explicit safer-sex be engaging in risky sex three months after the risky sexual behaviour A sex worker in Mongolia, guidelines resulted in lower rates of risky sex two intervention. The authors concluded that the erotic compared to non-erotic personal testimony told to months after the intervention among men who have programme including sexually explicit visuals was approaches.” Cheryl Overs. sex with men. The study, which involved more than most effective in helping men to adopt low-risk or no- – Richert, 2003 – Knerr and Philpott, 2008 600 gay or bisexual men, found that visual – as risk sexual behaviour; and although many of the men opposed to verbal and written – presentation of continued to have unsafe sex, they reduced by nearly affirmative, erotically appealing material was the most one-third the number of times they had intercourse effective among the following four HIV prevention without condoms (Quadland et al., 1987, in Kelly and interventions: Kalichman, 1995; Marlatt, 1998). In an article about

32 33 What are safer sex skills and How do 16. why are they you eroticise important? safer sex? Quick and dirty answer: Practicing sexy safer-sex is not necessarily innate or natural Quick and dirty answer: for most people – it’s something people learn through Rub the inner ring of a female condom on instruction and practice. Safer sexual skills can increase the her clit. Tell your man his penis is thicker and likelihood that people will practice safer sex (and enjoy it!). better with a condom. Put your latex glove on with a good ‘SNAP!’. Talk to a sex worker The focus on disease avoidance in safer-sex on a pleasure scale, it was found that safer-sex about what gives him or her pleasure. And interventions and research has left a crucial area behaviours were more pleasurable six months after relatively unexplored: the need for sexual skills and an intervention than immediately after the intervention that’s just the tip of the erotic iceberg... the ways in which skills influence the practice of (Kelly, St. Lawrence and Brasfield, 1989, in Kelly and safer sex. The widespread assumption is that sex is Kalichman, 1995). At six months, those participants According to Abramson and Pinkerton (2002), making they cite evidence that skilled sex workers can hide a something natural and automatic, especially for men still practising safer sexual behaviours reported these condoms part of foreplay could have a major bearing rolled-up condom in their cheek and then secretly slip (in a similar way that giving birth and breastfeeding, to be more pleasurable than unsafe activities. The 17.on how people perceive condom use and even on it onto a customer while performing oral sex. for example, are thought to be ‘natural’ and authors concluded that safer-sex interventions need the level of pleasure people experience during sex. ‘automatic’ for women). Yet evidence shows that safer to be long enough and engaging enough to maintain This requires a degree of creativity in practising sex becomes more comfortable and pleasurable with change until this transition occurs. safer sex and using safer-sex technologies. For Moore describes practice and through learning safer-sex skills. example, in the early part of the AIDS epidemic, In studies with sex workers, participants found it a group of sex workers some gay men ‘reshaped’ the pursuit of anonymous The few studies undertaken in the area of sexual easier to use a safer-sex technology on subsequent from San Francisco who sex by establishing ‘jack-off’ clubs and through the skill as it relates to safer sex show that people occasions, as they gained experience with the eroticization of safer-sex techniques (Greenberg, have become “extremely become more comfortable and satisfied, and often method, compared to their first time (Moore, 1997a). 1995). ‘Jack-off’ clubs were events where men experience more pleasure, the more they use a safer- This was particularly true with the female condom: sophisticated in their could come together to masturbate or provide hand sex technology, such as male and female condoms sex workers said they experienced more pleasure innovations and expressions stimulation to each other, sometimes while viewing (Kelly, 1989; UNAIDS and WHO, 2000). Ross (1992) and less discomfort after using it several times; and of eroticism and use of safer pornography, but with the explicit intention of not cites evidence that men who have gained ‘condom female condom acceptability trials, in a variety of sex technologies”. They engaging in penetrative sex. Moore (1997) describes skills’ have more positive attitudes towards condoms. settings, found that users were more comfortable a group of sex workers from San Francisco who have use latex gloves for fisting Conversely, in Bangladesh, Khan (2004) found using the female condom after they had tried it on become “extremely sophisticated in their innovations and cunnilingus, and ‘snap’ that, behind the explanation that ‘condoms reduce several occasions (WHO and UNAIDS, 2000). The and expressions of eroticism and use of safer sex pleasure’, is a fear of incompetence and lack of skill same appears to be true for the male condom, as the gloves on as they get technologies” (p434). They use latex gloves for fisting when using condoms. discussed by Khan (2004), but this type of scrutiny dressed for sex.” and cunnilingus, and ‘snap’ the gloves on as they get has not been applied to the male condom, perhaps – Knerr and Philpott, 2008 In a study of men who have sex with men, which dressed for sex. Abramson and Pinkerton (2002) also because it is not a new technology. asked participants to rate certain behaviours describe innovations developed by sex workers –

34 35 Despite the widespread belief that male condoms Furthermore, a study with men in Turkey found that reported that having regular, consistent clients provided decrease intimacy by forming a barrier between the common practice of early penis withdrawal during more economic stability, the Trust emphasized that “you partners, they have been used as tools to increase One of the clinic’s female sexual intercourse was due to participants’ beliefs are being paid to pleasure a client … do it well, and he intimacy and pleasure. For example, a pilot project in clients described how she that it increased their partners’ pleasure. Many of or she will call you back … satisfy him – kiss, perform three family-planning clinics in Brazil, Honduras and persuaded her husband the participants said they got the idea for this type foreplay, use your tongue, do oral sex, ask them how Jamaica trained counsellors to discuss condoms from to use condoms by saying of withdrawal from porn films, where ejaculation they feel... ” The Trust described this as “pleasure the viewpoint of sexuality rather than just contraception that his penis was thicker was taking place outside the vagina, and that this with economics”. Hazra (2006) recommends a similar (Becker et al., 1997). One of the clinic’s female clients led them to believe withdrawal could be a method of approach among male sex workers and masseurs in described how she persuaded her husband to use and more pleasurable contraception (Ortayli et al., 2005). India, with a focus on improving the health and safety condoms by saying that his penis was “thicker and with a condom.” of both the workers and their clients. Condoms can also be promoted as a tool for more pleasurable [with a condom]” (ibid, p26). – Becker et al., 1997 prolonging erection and delaying ejaculation, The St. James Infirmary (SJI) provides counselling to Female condoms have a strong record of being all over” a woman’s body rather than ejaculating in particularly among young men (Flood, 2003; Khan, sex workers in San Francisco, with a twist: used erotically. For example, there is anecdotal her vagina or anus (Flood, 2003). While withdrawal 2004). According to Khan (2004), condoms which “In its counselling sessions, SJI asks sex workers: evidence that female sex workers in some countries before ejaculation is not considered a ‘safe’ sexual prolong intercourse could become “the choice of the “What do you like about the work you do? What have charged men more money to have sex with a practice per se, there is evidence that ‘cumming’ sexually skilled man”. Others point out the difficulties gives you pleasure?” With this as a springboard, female condom than without, by talking about the outside the vagina or anus does reduce the likelihood of this approach, recommending that condom sex workers are encouraged to talk about all female condom as if it is a new sex toy (Hapugalle, of HIV transmission (Richters, 1994). Heterosexual education should be honest about the potential for aspects of their work – what they like and don’t like, 2002, or telling clients ‘it only makes noise when pornography already eroticizes ejaculation on, rather condoms to reduce sensation and about the fact what they are willing to do and what they aren’t men are good” (Prasad, personal communication, than in, a woman’s body in the so-called ‘money that most men experience erection loss at one time willing to do. This kind of discussion with qualified Philpott, 2006). By allowing clients to insert the shot’ or ‘cum shot’ and in the ‘facials’ genre, which is or another, and encourage young men to practise counsellors can then lead to conversations about female condom into their vagina, and presenting devoted to the practice of showing men ejaculating using condoms while masturbating (Flood, 2003). how to do the work they do in the safest way this as a pleasurable and intimate act, they are onto women’s faces. Thus, the addition of safer- As previously stated, some commercial condom possible.” (Knerr and Philpott 2008, p68) breaking a major taboo against men looking at or sex elements to these representations could make companies have seized on the idea of prolonging having intimate contact with female genitalia. Among them useful in HIV prevention campaigns (Flood, erection using condoms by introducing condoms Other examples include work with faith-based some transsexual men who have sex with men in 2003). While these observations provide insight treated with an anaesthetic gel preparation; for communities in Nigeria and Mozambique, where non- India, the female condom is used to emphasize their into how existing pleasure constructs could be used example, see www.freepatentsonline.com/7086403. governmental organizations worked to increase the femininity to male partners and for anal sex by the to enhance prevention messages, they should be html.; www.durexhcp.co.uk/products/condoms/) experience of pleasurable sex among married couples. receptive partner (Hapugalle, 2002). Other users considered within the context of women’s desires The aim was to improve sex in marriage so that men, In some cases, safer-sex interventions have led report enjoying the friction of the outer and inner as well, for example, through research into women’s in particular, were less likely to seek out other sexual to eroticization of a method while also opening up rings as they have penetrative sex (Philpott, Knerr feelings about men ejaculating in or on their bodies. partners, thereby reducing a major risk factor for STIs. opportunities to discuss pleasure and desire. For and Boyden, 2006; Hapugalle, 2002). In India during example, in Kenya, women introduced to the female acceptability trials of the female condom, women condom through a research project were eager to were reporting having orgasms for the first time as In India during use the method, able to discuss taboo issues such as they inserted the condom into themselves, as the In Kenya, women desire and pleasure in the context of the project, and rings and lubrication made insertion a pleasurable acceptability trials of introduced to the female were initiating sexual encounters with their partners experience (Philpott, Knerr and Boyden, 2006). In the female condom, by inserting the device hours before intercourse, as a condom were initiating Senegal female condoms were promoted with erotic women were reporting sign that they wanted to have sex (Ankrah and Attika, sexual encounters with beads and as a condom for men with larger penises having orgasms for 1997). Therefore, the effect of introducing the female (SWAA, personal communication) and in Ghana and their partners by inserting the first time as they condom to participants was not only safer sex, but Zimbabwe men were promoting the female condom the device hours before also a degree of empowerment and sexual agency. to their male friends through discussion of how the inserted the condom into intercourse, as a sign that inner ring of the female condom creates pleasure as themselves, as the rings Knerr and Philpott (2008), in The Global Mapping they wanted to have sex it rubs on the penis (Philpott 2006.). and lubrication made of Pleasure, 2nd Edition, describe 47 programmatic ... it gave them a degree and media examples of how safer sex has been There are also examples of sexy safer-sex skills insertion a pleasurable of empowerment and eroticized in a wide range of cultures and contexts. which do not involve condoms. For instance, some experience.” For example, they describe the Samabhavana Trust’s sexual agency.” heterosexual men derive pleasure from “cumming – Philpott, Knerr and Boyden, 2006 work with male sex workers in India. When the men – Ankrah and Attika, 1997

36 37 Still from the erotic film Modern Loving by UK filmmaker Anna Span featuring hetrosexual couples practicing safe sex How can we teach people (or how do they learn) about sexy safer-sex? Quick and dirty answer: By finding out how people in different cultures, countries, contexts, age and gender groups learn about sex and sexuality. Consider porn and romance, for example, as potential (and enticing) means through which to communicate safer sex skills. 18.

While it’s obvious safer-sex skills can be taught is not a completely reliable form of contraception, it point for effective safer sex strategies is to consider through ordinary sex education programmes is a form of risk reduction and helps us think through how desire is currently most pleasurably elaborated” and campaigns, it is important to consider more how to present risk reducing practises. We must also get creative for a particular group (2001, p243). She goes on provocative modes of communication, too. This about other modes for to point out that romance, as it is understood in the Sex workers in the USA have also reported learning includes pornography and romance, and talking to context of some women’s desire, could also be a how to hone their skills from more experienced delivering information ‘experts’ who already know how to eroticize safer useful site for safer-sex promotion. women and from the media, such as pornographic about safer-sex skills – such sex; such as sex workers and gay men. films. (Notably, some of them also report contacting as through pornography Some critics argue that “young women’s commitment Many people learn about sex through porn (Warr, health institutions, such as the Centers for Disease and romance, and by to popular forms of romantic love place high value on 2001), thus porn could be an important medium for Control (CDC), to check on the safety of particular looking to ‘experts’ who sexual exclusivity, trust, and surrender” (Warr, 2001, communicating about safer sex. Examples of this sexual practices as a way to continually update their p243), which are all concepts that tend to reduce include films by UK filmmaker Anna Span and the knowledge. This has subsequently provided new already know how to condom use, since people are less likely to use instructional series for heterosexual couples Modern information to the CDC about the variety of new eroticize safer sex.” condoms with steady partners as a sign of trust in the Loving, both of which feature actors and actresses behaviours being practised (Moore, 1997). other person (Escabi et al., 2004; Kamya et al., 2002; using male and female condoms and lube as part of While porn is a common medium for learning Foss et al., 2004; Salazar et al., 2002). But there are In another example, gay-porn filmmaker Chi Chi sex play (Knerr and Philpott, 2008). Many porn films about sex, some people suggest that using compelling arguments to be made for offering safer- La Rue taught people about the dangers of anal show men ejaculating outside a woman’s vagina or it to communicate safer-sex skills could be sex education which is relevant to young women’s sex without condoms (a.k.a. ‘barebacking’) in gay anus, which some men say is a motivation for them to counterproductive if other aspects of the genre experiences, while also working to transform gender porn films by creating sexually explicit short films practice coital withdrawal as a form of contraception reinforce harmful gender stereotypes or promote norms which disadvantage women. While it must on the internet, with voiceover messages against (e.g., this was the case among men in Turkey violence (Flood, 2003; Wilton, 1994, in Warr, 2001). be acknowledged that the romantic narrative may at ‘barebacking’ (Knerr and Philpott, 2008). according to Ortayli et al. (2005)). While withdrawal However, according to Warr, the “most useful starting times put women at risk, it can also be argued that:

38 39 “[r]omance gives meaning and impetus to sex that Efforts to use pornography to deliver safer-sex Africa, Latin America and elsewhere…” He says, should be acknowledged in safe sex education. information have been shown to be effective, “there are all kinds of indigenous words to describe all It is necessary to consider the possibilities particularly among men (Kyes, Brown and Pollack, Equally important kinds of arrangements. There is no universal system of women’s interest in romance to avoid an 1991; Quadland et al., 1987, in Kelly and Kalichman, is to use narratives and of sexual organisation, no definitive set of traditions, unintended effect of safe sex promotion in further 1995; Marlatt, 1998).To this end, Singhal (2003) modes of communication no single vocabulary. And so, in strategising around denigrating and marginalizing the concerns and argues that communication interventions for HIV sexual rights in development, the cues must come experiences of women. The meanings of romance prevention should view culture as an ally, reconstruct that resonate within from the ground, from the people who live and are not fixed and immutable, and we need to think cultural rites, employ culturally resonant narratives, a culture or context, appreciate the particularities of their unique cultural about how it can be represented to reflect different and create a culture-based pedagogy of HIV rather than trying to use contexts” (Gosine, 2005, p22). sets of concerns as well as more diverse fields of prevention. This is in line with the argument for safer- the scientific or rational Finally, Singhal (2003) notes that what is often desire and pleasure.” (Warr, 2001, p251) sex interventions that involve participatory processes approach to health missing from intervention programmes is a aligned with concepts of sex and pleasure in each Thus, while the form romance currently takes in many consideration of the social construction of ‘love’, culture and context (Gordon and Lewis, 2006). While communication common cultures seems to discourage safer sex, this is not which involves risk-taking, trusting and giving – some may see existing health beliefs as barriers, that in ‘western’ contexts. necessarily an intricate characteristic of romance, but all elements that can contribute to unsafe sex. culture can be seen as a strength, with elements that This could include oral rather one set of meanings that it has acquired. Prevention programmes which teach about ‘love’, may support HIV and AIDS prevention (Singhal, 2003). communication methods, such as comprehensive ‘sex and relationship’ HIV prevention strategies should (ideally) aim Equally important is to use narratives and modes for example, which are education programmes or faith-based programmes to support long-term social change in relation to of communication that resonate within a culture more prominent as a way which promote marriage, in fact are promoting some gender norms which disadvantage women. Yet “the or context, rather than trying to use the scientific elements of love while turning away others. balance between short-term, pragmatically motivated of learning in many parts or rational approach to health communication approaches and the long-term aim of fundamental of the world.” common in ‘western’ contexts. This could include social change is a complex and contested one” oral communication methods, for example, which are – Singhal, 2003 (Flood, 2003, pp15-16). There is no universal more prominent as a way of learning in many parts “…Given that ‘good lover’ narratives involve men’s of the world (Singhal, 2003). With regard to women, a term and context that was familiar to the target system of sexual production of women’s sexual pleasure, men’s in particular, the challenge “is to work with women’s community: organisation, no definitive understanding of the conditions necessary for this own ways of communicating about sex, from riddles “[t]he ssenga model is built on the premise that set of traditions, no single pleasure could be broadened to include women’s to songs to games, and to draw on local practices sexuality is influenced by tradition and that vocabulary. And so, in sense of prophylactic safety: ‘How can she have in culturally sensitive ways, rather than assuming behaviour change should be initiated within strategising around sexual an orgasm when she’s worrying about getting a that they are always problematic or ignoring their the context of existing cultural systems. The rights in development, the disease?’” (Flood, 2003, p14). existence” (Tamale, 2006, as cited in Cornwall, 2006, approach emphasized community participation, pp281–2). cues must come from the utilization of local knowledge and skills and the ground, from the people Most cultures have existing constructs that are accessibility of ssengas as woman teachers. Singhal argues that potentially beneficial for safer-sex programmes, if Community participation increased the flexibility who live and appreciate communication only the people running the programmes were aware of the initiative and its responsiveness to local the particularities of their interventions for HIV of them. An example is the Ugandan tradition of the conditions,” (Muyinda et al., 2003, p165) unique cultural contexts.” ssenga, through which girls are taught by their older prevention should This is just one example of how an existing institution – Gosine, 2005 female relatives, especially aunts, about sexuality, can be used, but not abused, to further sexual health. view culture as an ally, menstruation and marriage, among other things reconstruct cultural rites, (Tamale, 2006). Muyinda,et al. (2003) conducted an Sometimes, pre-existing norms can be easier to work employ culturally resonant HIV education effort based on the ssenga model. with than the models promoted by sex education narratives, and create a They trained several women within the community programmes. For instance, Gosine (2005) points culture-based pedagogy about sexual health, HIV and contraception. These out the surprise that some western gay and lesbian women then returned to their communities, where activists express when they learn about “the complex of HIV prevention.” they were seen and used as a resource. They used and fluid notions of sexual identity in South Asia,

40 41 The implications of gender and culture on concepts and experiences of sex, sexual pleasure and safer sex must be at the core of pleasure-oriented and erotic interventions. This is essential for understanding the subjective nature of sex, pleasure and safer sex, and for identifying the groups most responsive to erotic safer- What do we sex interventions.”

recommend? understanding the subjective nature of sex, pleasure skills and definitions beyond ‘sex as penetration’; challenge and safer sex, and for identifying the groups most gender roles and assumptions that may disempower responsive to erotic safer-sex interventions. We must people, particularly women, when it comes to sex and ask: ‘How is pleasure defined in this setting?’ and safer sex; and support the notion of sex and sexuality Quick and dirty answer: ‘How are sex and pleasure experienced?’ This could as forces for good, rather than vectors of disease. More and better research in more places, with more also incorporate notions of love, which are often This will require those who do safer-sex research and diverse groups of people. More culturally relevant missing in safer-sex promotion. messages, with more pleasure and sex, and less talk programmes – researchers, implementers, designers, of fear, risk and disease. Talking to people who know Collaboration across disciplines is evaluators, and funders – to think about sex in a recommended for effective intervention realistic, non-judgemental way, and to come to terms a lot about (pleasurable) sex (i.e., sex workers). 4design. Developing pleasure-oriented with personal obstacles which may have a negative programmes requires in-depth understanding of effect on their work to promote pleasurable or sex- 19. how sex and pleasure are experienced, defined and positive safer sex. understood in different contexts, and a much broader Test alternative modes of delivering safer-sex There is good evidence that incorporating pleasure Existing erotic intervention studies that understanding of the practice of, purposes for and information and develop new allies. Research into safer-sex and HIV prevention programmes is show causal links must be adapted to motivations behind sexual behaviour. There is a 6and programmes should test communication a relatively unexplored but promising approach to wider contexts. Studies showing a link wealth of knowledge about these subjects coming 2 methods for delivery of safer-sex messages, promoting safer sex. In light of this, we offer the between eroticizing safer sex and behaviour from non-biomedical disciplines, such as anthropology, and consider alternative and popular modes of following recommendations: change need to be adapted for higher-risk contexts, psychology, sexology, communications and marketing, communication, such as pornography and romance. particularly settings in Africa, Asia and Latin America, which can bolster public health investigations of sexual More research to establish causal links. Research should ask: Where do target populations and groups most vulnerable to HIV. This review cites pleasure as a motivator for behaviour change. There is an urgent need for more research learn about sex? Can we promote safer sex through some of the key studies that demonstrate these 1into the impact of pleasure and eroticism on In addition, there is also a strong argument for erotic films? If so, in which countries and contexts? links; Scott-Sheldon and Johnson (2006), in particular, the effectiveness of safer-sex and HIV prevention collaborating with researchers who are developing Are sex education films more effective than safer-sex analysed a range of studies and demonstrated interventions. This should involve developing new and investigating new safer-sex technologies, such porn in reducing risk behaviour? causality. Unfortunately, most of those interventions interventions that use an erotic and/or pleasure as microbicides. Microbicide research has revealed took place in very limited contexts, and adaptation of In addition, key populations, such as groups and component, and evaluating new and existing the erotic potential of this technology, which could these successful studies to higher-risk contexts is vital. organizations of sex workers and gay men, can programmes of this type, such as some of those dovetail nicely with erotic safer-sex research. often know how to motivate safer sex in positive cited in The Global Mapping of Pleasure, 2nd Edition Research interventions must be developed Shift the focus of safer-sex and HIV prevention ways, and should be seen as allies and agents of (Knerr and Philpott, 2008). It is particularly important with an understanding of how gender and interventions from disease, risk and AIDS to change in efforts to promote safer sex aimed at a that studies examine the causal relationships culture influence sex, sexual pleasure and 3 5enhancement of pleasure, sexual skill and range of audiences. Practising safer sex requires between eroticization and behaviour change: safer sex. The implications of gender and culture on eroticism. This requires more than just the inclusion of a skills and confidence, as well as creativity, which can comparing erotic safer-sex interventions with non- concepts and experiences of sex, sexual pleasure minor erotic element in a broader sexual health or sex sometimes best be learned from those who already erotic safer-sex interventions will help to provide and safer sex must be at the core of pleasure- education programme. It should: involve interventions know how to make safer sex sexy. more conclusive evidence of impact. oriented and erotic interventions. This is essential for which help subjects to develop sexual self-confidence,

42 43 We have included all of the research, commentaries and interventions that we were able to identify Where did and access which linked safer sex with pleasure or eroticism. Research that focused on successful safer- we get our sex practitioners and examples of the eroticization of answers from? technologies for safer sex are also included.”

(i.e.what was our We searched the scientific literature, including We have included all of the research, commentaries conference presentations, publications of national and interventions that we were able to identify and and international organizations, and lay media. access which linked safer sex with pleasure or eroticism. Research that focused on successful safer- methodology?) We searched records on PubMed, Medline, sex practitioners and examples of the eroticization ScienceDirect and the Google search engine until Quick and dirty answer: of technologies for safer sex are also included, as is February 2008, using combined search terms that some grey literature. We conducted a basic literature review, included the word ‘pleasure’, for example, ‘pleasure using standard online databases for scientific and sexual health’, ‘pleasure and reproductive The authors recognize that this report may not articles, as well as gray literature sources. health’, and ‘pleasure and condoms’. We searched represent the entire evidence base on safer sex Eldis, Intute, Global Development Network, Siyanda and pleasure/eroticism,,and look forward to any and Population Council up to April 2008, using the oversights or new materials being brought to our search terms ‘pleasure’, ‘condom’ and ‘erotic’. And attention. We recognise that within a limited research we searched the abstract database for international field the evidence on queer sexualities (besides men AIDS conferences from 2001–2007 using the search having sex with men) is even more limited and this terms ‘pleasure’ and ‘erotic’. We also requested review struggles within this limitation. For the most relevant articles and studies from professional part, studies in which pleasure was noted as a reason contacts and from the reference list of our previously for not engaging in safer sex are not considered, published article in The Lancet (Philpott et al., 2006). for while these studies make up part of the rationale As a parallel process, we researched data for the for undertaking this work, pleasure as a barrier to publication The Global Mapping of Pleasure, 2nd practising safer sex is well documented. Edition, a directory of 47 case studies of people, organizations and programmes that eroticize safer sex, which brought up research and grey literature relevant to this literature review.

2. http://www.thepleasureproject.org./section10/ 44 20. 45 Advancement of Women (DAW) in collaboration with International Labour Organization, Joint United Nations Programmes on HIV/AIDS (UNAIDS), United Nations Development Programme (UNDP), Expert Group Meeting on ‘The role of men and boys in achieving gender equality’ 21–24 October 2003, Brasilia, Brazil. http://www.un.org/womenwatch/ daw/egm/men-boys2003/EP6-Flood.pdf

Fort, S (2006) ‘Fatal Error, Bush’s global AIDS plan ignores reality and endangers women’s lives’, Ms Magazine, Fall. www.msmagazine.com/fall2006/fatalerror.asp.

Foss, AM, Watts, CH, Vickerman, P, and Heise, L (2004) ‘Condoms and prevention of HIV - Are essential and effective, but additional methods are also needed’, British Medical Journal, 329;7459:185. http://www.bmj.com/cgi/content/full/329/7459/185

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